Trends in the prevalence, awareness, treatment and control of hypertension: the WHO MONICA Project.

OBJECTIVE: To describe the secular changes in the prevalence, awareness, treatment and control of hypertension. DESIGN: Two independent cross-sectional population surveys using standardized methods conducted between the early 1980s and mid-1990s. SETTING: Twenty-four geographically defined populations of the WHO MONICA Project. PARTICIPANTS: Randomly selected men and women aged 35-64 years. The total number of participants was 69 907. MAIN OUTCOME MEASURES: Two definitions of hypertension were used: 160/95 mmHg or above and 140/90 mmHg or above for systolic or diastolic blood pressure. Subjects on antihypertensive drug treatment were considered to be hypertensive regardless of their blood pressure. Treated subjects whose measured blood pressure level was less than 160/95 or 140/90 mmHg according to the two definitions, respectively, were considered to be adequately treated. RESULTS: The age-adjusted prevalence of hypertension decreased in most and increased in only a few populations. For both definitions of hypertension, the proportion of hypertensive subjects who were aware of their condition increased in three-quarters of the male populations and in two-thirds of the female populations. Furthermore, the proportion of hypertensive individuals on antihypertensive drug treatment increased in three-quarters of the populations. In the final survey, hypertension tended to be better treated and controlled in women than in men. Nevertheless, a large proportion of patients receiving antihypertensive drug therapy still had inadequately controlled blood pressure levels. CONCLUSION: Although awareness and treatment of hypertension according to the data obtained during the late 1980s to the mid-1990s increased in several populations, the effectiveness of antihypertensive treatment showed the continuing need for improvements.     

Myeloperoxidase, but not oxidized LDL, is associated with leisure-time physical activity: results from the MONICA/KORA Augsburg Studies 1984-1995

Objective

Oxidative stress-induced cell damage contributes to several chronic conditions such as cardiovascular disease, but only very few population-based studies have examined the influence of regular physical activity (PA) on oxidative stress.

Methods

1820 men and women aged 35–74 years were randomly drawn from three population-based MONICA/KORA Augsburg Studies conducted between 1984 and 1995. Geometric means of the oxidative stress markers myeloperoxidase (MPO) and oxidized LDL (ox-LDL) were calculated and multiple linear regression was performed to assess their associations with three self-reported PA domains, namely work, leisure-time or walking.

Results

Mean MPO concentrations were lower for participants engaged in high leisure-time PA (124.2 μg/ml; 95%-CI, 116.8–132.0) compared to the inactive reference group (133.5 μg/ml; 95%-CI, 127.6–139.6) (P_trend across PA levels: 0.007). No significant association between ox-LDL and PA domains was observed (P_trend between 0.162 and 0.803).

Conclusion

These data indicate that regular leisure-time PA may reduce MPO concentrations.     

Trends in the in-hospital treatment of acute myocardial infarction between 1984 and 1993 - The Halifax County MONICA Project

BACKGROUND: The Halifax County MONItoring of trends and determinants in CArdiovascular disease (MONICA) Project found that between 1984 and 1988, the proportion of myocardial infarctions (MIs) that were fatal within 28 days remained constant, but declined between 1989 and 1993. The objective was to investigate association among case fatality, treatment and case severity of MI in hospitalized patients. PATIENTS AND METHODS: The MONICA MI register contains data on demographics, health history, in-hospital investigations, interventions and treatment, and vital status at 28 days after onset of symptoms for all MIs occurring in residents of Halifax County, aged 25 to 74 years. Logistic regression analysis was used to estimate trends in the use of cardioactive drugs and revascularization procedures. A case severity score was developed from patient characteristics at time of admission. Case fatality was calculated as the proportion of MIs that were fatal within 28 days. RESULTS: Between 1984 and 1988, a large increase (OR 1.3) occurred in the use of angiotensin-converting enzyme (ACE) inhibitors, acetylsalicylic acid (ASA), thrombolysis and percutaneous transluminal coronary angioplasty (PTCA); a minor increase occurred in use of calcium channel blockers (OR=1.29, 99% CI 1.19 to 1.40); beta-blocker use decreased; case fatality remained constant and case severity score increased. From 1989 to 1993, ACE inhibitor use increased (OR=1.4, 99% CI 1.27 to 1.55); minor increases occurred in use of ASA and beta-blockers, and in PTCA and coronary artery bypass grafting; case severity did not change and case fatality decreased. CONCLUSIONS: While use of beneficial treatment increased between 1984 and 1988, MI case fatality did not decrease, probably because case severity increased. Between 1989 and 1993, case severity remained constant, and the further increase in the use of beneficial therapy was associated with a decline in case fatality.     

C-reactive protein as a predictor for incident diabetes mellitus among middle-aged men: results from the MONICA Augsburg cohort study, 1984-1998

BACKGROUND: Previous studies have suggested that low-grade systemic inflammation is involved in the pathogenesis of type 2 diabetes mellitus. OBJECTIVE: To investigate the association between C-reactive protein (CRP), the classic acute-phase protein, and incident type 2 diabetes mellitus among middle-aged men. METHODS: A total of 2052 initially nondiabetic men aged 45 to 74 years who participated in 1 of the 3 MONICA (Monitoring of Trends and Determinants in Cardiovascular Disease) Augsburg surveys between 1984 and 1995 were followed up for an average of 7.2 years. Incidence of diabetes was assessed by questionnaire mailed to participants in 1998. High-sensitive CRP was measured by an immunoradiometric assay. RESULTS: A total of 101 cases of incident diabetes occurred during the follow-up period. The age-standardized incidence rate was 6.9 per 1000 person-years. Men with CRP levels in the highest quartile (CRP > or = 2.91 mg/L) had a 2.7 times higher risk of developing diabetes (95% confidence interval, 1.4-5.2) compared with men in the lowest quartile (CRP < or = 0.67 mg/L) in a Cox proportional hazards model adjusted for age and survey. After further adjustment for body mass index, smoking, and systolic blood pressure, the observed association was significantly reduced and became nonsignificant. CONCLUSIONS: Low-grade systemic inflammation is associated with an increased risk of type 2 diabetes mellitus in middle-aged men. Inflammation could be one mechanism by which known risk factors for diabetes mellitus, such as obesity, smoking, and hypertension, promote the development of diabetes mellitus.     

Alcohol and blood pressure and its interaction with smoking and other behavioural variables: results from the MONICA Augsburg Survey 1984-1985.

Data from the Augsburg Survey 1984-1985 of the WHO-project Monitoring Trends and Determinants in Cardiovascular Disease (MONICA), a cross-sectional study on a two-stage cluster sample (n = 5312) of the 25-64-year-old population of the Augsburg study area, were analyzed with regard to alcohol consumption and blood pressure. Putative confounders such as age, body mass index, smoking, sporting activity and educational attainment were controlled for by multiple regression analyses. The main effect models showed that men aged 25-64 years consuming greater than or equal to 80 g alcohol per day had, on average, 3-11 mmHg higher systolic blood pressure (SBP) values and 2-6 mmHg higher diastolic blood pressure (DBP) values compared with non-drinkers. Women consuming greater than or equal to 40 g alcohol per day showed consistently higher SBP (2-6 mmHg) and DBP (1-5 mmHg) values compared with non-drinkers. In the group aged 55-64 years, no clear relationship was seen for SBP or DBP in men or women. Multiple regression models, allowing for interactions between alcohol consumption and the four behavioural variables: smoking, sporting activity; coffee consumption; and type A/B behaviour, showed a consistent interaction between alcohol consumption and smoking in men and women. Smoking modified the effect of alcohol on SBP and DBP in men by 2-8 mmHg and in women by 1-14 mmHg. These findings confirm those obtained for women in previous studies in Munich and Lübeck. Interactions between alcohol and sporting activity, coffee consumption and type A/B behaviour are less consistent.     

Macrophage migration inhibitory factor (MIF) and risk for coronary heart disease: results from the MONICA/KORA Augsburg case-cohort study, 1984-2002

Objective

Macrophage migration inhibitory factor (MIF), a central cytokine of the innate immunity, has been reported to contribute to the development of cardiovascular disease. MIF is expressed in atherosclerotic lesions in humans, and gene deletion and antibody inhibition studies in animal models indicated that MIF may be cause rather than consequence of atherosclerosis. We sought to assess the triangular association between MIF genotypes, circulating MIF levels and risk for incident coronary heart disease (CHD) in the large, prospective, population-based MONICA/KORA case-cohort study (Augsburg, Southern Germany).

Methods

MIF genotypes, haplotypes and serum concentrations were determined in 363 individuals with incident CHD and 1908 individuals without CHD during follow-up (mean follow-up time 10.3 years).

Results

Circulating MIF concentrations were not associated with the risk for CHD. In women, carriers of the minor alleles rs755622C and rs2070766G had a higher risk for incident CHD, and a haplotype that contained these two minor alleles was significantly associated with increased risk for CHD (HR 2.44, 95%CI 1.30–4.59).

Conclusion

The lack of association between serum levels and incident CHD indicates that MIF may not be a novel biomarker for CHD risk. However, the association of a haplotype containing the rs755622C allele, which has been reported before to increase the susceptibility for various other proinflammatory conditions, with CHD points towards a role for MIF in local vascular inflammation and atherogenesis.     

Microalbuminuria, central adiposity and hypertension in the non-diabetic urban population of the MONICA Augsburg survey 1994/95.

OBJECTIVE: Microalbuminuria is a renal marker of general vascular endothelial damage and early atherosclerosis with adverse prognostic implications. Microalbuminuria is associated with diabetes, insulin resistance, central adiposity and hypertension. We evaluated the degree of the association of components of the metabolic syndrome with microalbuminuria in a subsample of a non-diabetic study population. DESIGN: Men and women aged 25-74 living in the city of Augsburg, Germany, were interviewed and examined in a standardised manner at a population-based survey conducted in 1994/95. Persons with a history of diabetes or HbA1c level > or = 7% were excluded. OUTCOME: Albumin and creatinine were determined quantitatively in a spot urine and defined as microalbuminuria via an albumin/creatinine ratio between 30 and 299 mg/g. RESULTS: Among 920 men and 879 women, the age- standardised prevalence of microalbuminuria was 8.0% and 7.5%, respectively. While a graded, positive increase in prevalence of microalbuminuria across quintiles of waist-to-hip (WHR) was observed in non-hypertensive men and women, microalbuminuria was uniformly high among hypertensives. Multivariate logistic regression models showed that central adiposity (OR 3.3) or hypertension (OR 4.0) alone significantly increased the odds of microalbuminuria while their joint presence (OR 3.6) did not add to the occurrence of microalbuminuria. While obesity was not associated with microalbuminuria once central adiposity was taken into account, elevated percent body fat remained associated with microalbuminuria. CONCLUSIONS: Signs of early endothelial dysfunction as manifested as microalbuminuria are strongly and independently associated with central adiposity and should be considered in the context of the metabolic or insulin resistance syndrome.     

Trends in the incidence of acute myocardial infarction between 1984 and 1993 - The Halifax County MONICA Project

BACKGROUND: According to vital statistics data for Halifax County, between 1984 and 1993 the annual mortality rate decreased for ischemic heart disease and myocardial infarction (MI). OBJECTIVES: To estimate the change in MI mortality, applying standardized diagnostic criteria; to determine whether decreased case fatality or decreased MI event rate, or both, caused decreased mortality; and to determine the contribution of MI incidence rate to altered event rate. PATIENTS AND METHODS: All persons in the study area aged 25 to 74 years and admitted to hospital or dying outside hospital with suspected acute coronary syndromes were registered prospectively. Demographic, health history and clinical data were extracted from medical records or collected from medical examiner reports, next-of-kin interviews or family physicians. Definite or possible MI was diagnosed according to World Health Organization MONItoring of trends and determinants in CArdiovascular disease (MONICA) criteria. Trends in age- and sex-standardized rates were estimated by using log-linear regression analysis. RESULTS: Of 4283 patients admitted to hospital for MI, 23.9% died within 28 days; 1401 patients who had suffered an MI died before admission to hospital. MI mortality decreased annually by 3.9% (95% CI 1.9 to 5.8); two-thirds of the decline was due to MI event rates (2.6%; CI 1.3 to 3.8) and one-third to a decrease in 28-day case fatality (1.3%; CI 0.2 to 2. 3). A decrease in MI incidence rate (3.2%; CI 1.7 to 4.8), rather than a decline in MI recurrence rate (1.4%; CI 0.7 to -3.5), was the major reason for the declining event rate. CONCLUSIONS: A decrease in the incidence of MI, possibly due to primary prevention, had a major impact on the declining MI mortality. Decreased in-hospital MI fatality, possibly due to improved treatment, was responsible for the decline in case fatality.     

Haematocrit levels and left ventricular geometry: results of the MONICA Augsburg Echocardiographic Substudy

BACKGROUND: Extreme alterations in blood count such as anaemia or polycythemia are known to cause circulatory changes and, if these alterations persist, adaptations of cardiac geometry. OBJECTIVES: To investigate further the association between haematocrit levels and left ventricular geometry in a population-based sample. METHODS: We examined 687 women and 648 men, aged 25-74 years, participating in the third population-based MONICA Augsburg study. Anthropometry, blood pressure, laboratory measurements and M-mode echocardiography were obtained using standardized methods. RESULTS: Haematocrit levels were inversely related to end-diastolic diameters (P < 0.001). By contrast, septal and posterior wall thickness displayed parabolic association curves with nadirs at physiological haematocrit levels (P < 0.001). These associations remained significant after adjustment for age, sex, body fat, hypertension, diabetes mellitus, cardiovascular disease, heart failure, serum creatinine, and were likewise found for haemoglobin levels or numbers of erythrocytes. These correlations appeared to be secondary to changes in blood pressure and stroke volume that correlated either positively (blood pressure) or inversely (stroke volume) with haematocrit levels. Consequently, a concentric pattern of left ventricular hypertrophy, i.e. a relative wall thickness of 0.45 or greater, was significantly more prevalent in subjects with high haematocrit levels than in those with intermediate haematocrit levels. By contrast, an eccentric left ventricular hypertrophy, i.e. relative wall thickness less than 0.45, was more common in subjects with low haematocrit levels. CONCLUSION: In the general population, the variability of haematocrit levels and its haemodynamic consequences translates to distinct patterns of left ventricular geometry.     

Selected nutrient intakes of middle-aged men in southern Germany: results from the WHO MONICA Augsburg Dietary Survey of 1984/85.

In the WHO MONICA Augsburg survey of 1984/85 dietary intake was assessed in an age-stratified cluster sample of 899 men aged 45-64 years by 7-day records. The mean energy intake was 2,609 kcal (10.9 MJ), 15.9% of which came from protein, 38.1% from fat, and 36.6% from carbohydrate. A remarkably high proportion of 9.4% was derived from alcohol. Saturated fatty acids accounted for 14.6% of total energy, monounsaturated fatty acids for 13.2% and polyunsaturated fatty acids for 5.2%. The results showed that current dietary habits do not conform with the national nutritional guidelines.     

Trends and social factors in blood pressure control in Scottish MONICA surveys 1986-1995: the rule of halves revisited

Time trends and social factors in detection, treatment and control of hypertension in the community were examined in four independent Scottish MONICA cross-sectional surveys in 1986, 1989, 1992 and 1995. Residents aged 25-64 years were recruited randomly from general practice lists in north Glasgow, Scotland with stratification by sex and 10-year age groups. A total of 1262 participated in the first survey, 1397 in the second, 1516 in the third and 1836 in the fourth. Differences and trends in proportions of hypertension undetected, detected but untreated, treated but uncontrolled and controlled across the four surveys were tested by chi(2), and the associations of the poor control of hypertension with social factors were estimated by multivariate logistic regression model to derive odds ratios. Using the cut point of >/=160/95 mmHg, proportion of hypertension undetected across the four surveys was 56.3, 44.6, 32.0 and 38.2%, and of treated controlled hypertension was 15.2, 26.4, 32.0 and 32.8% (both trends P<0.001). Multivariate analysis showed that poor control of hypertension was not related to social deprivation, but significantly related to being male, young, of low body mass index and heavy alcohol drinking. Undetected hypertension was significantly related to full-time employment, and untreated hypertension to high social class and possibly education level. These findings suggest that in this part of Scotland the management of hypertension has improved, so the 'rule of halves' no longer applies. Control of blood pressure is not positively associated with social deprivation, but people at a high risk of poor control of hypertension should be targeted.     

Geographic variations in the prevalence,awareness, treatment and control of hypertension in China

OBJECTIVE: To compare the prevalence, awareness, treatment and control of hypertension in north and south, and urban and rural residents of China. DESIGN: A cross-sectional survey conducted in 2000-2001. SETTING AND PARTICIPANTS: A multistage cluster sampling method was used to select a nationally representative sample of 15 540 men and women aged 35-74 years from the general Chinese population. MAIN OUTCOME MEASURES: Three blood pressure measurements were obtained by trained observers using a standardized mercury sphygmomanometer. Information on history of hypertension and use of antihypertensive medications was obtained by use of a standard questionnaire. Hypertension was defined as a mean systolic blood pressure >or= 140 mmHg and/or diastolic blood pressure >or= 90 mmHg and/or use of antihypertensive medications. RESULTS: The age-standardized prevalence of hypertension was significantly higher among residents living in north than in south China (33.8 versus 23.3%, P < 0.001), but similar in those living in urban and rural areas (29.0 versus 28.1%, P = 0.3). Average systolic and diastolic blood pressure levels were consistently higher in north than in south residents. Residents in north China had higher percentages of awareness but lower percentages of control compared with their counterparts in south China. Percentages of awareness, treatment and control of hypertension were significantly higher in urban than in rural residents. CONCLUSIONS: Our study documents a marked north-south gradient in the prevalence of hypertension in China. The previously reported urban-rural difference in the prevalence of hypertension was not noted, perhaps due to a rapid increase in the prevalence of hypertension in rural China.     

Prevalence, treatment, and control of hypertension in primary care: gaps, trends, and opportunities

Since most cases of hypertension are managed in family practice, estimates of the prevalence, treatment, and control in the primary care population are needed to adequately address the burden of hypertension in Canada as it has in other countries. The authors used a large primary care research database to determine the prevalence of hypertension between 2000 and 2003. Blood pressure recordings were used to estimate the rates of prevalence, treatment, and control of hypertension for the overall population and for important subgroups. The prevalence of hypertension was 17.3%, most patients had untreated hypertension (68.6%), and only 15.8% had blood pressure treated and controlled. Higher rates of treatment and control were observed among older adults, those with type II diabetes, and those with a previous myocardial infarction. Odds of achieving target blood pressure were significantly better when combination therapy vs monotherapy was used. The prevalence of hypertension in primary care is high and most patients remain untreated; however, increased risk appears to lead to better treatment and control.